Disseminated Intravascular Coagulation The 5 Minute Pediatric Consult


	Disseminated Intravascular Coagulation

Sadhna M. Shankar

Database
Differential Diagnosis
Data Gathering
Physical Examination
Laboratory Aids
Therapy
Bibliography

DATABASE

DEFINITION

Disseminated intravascular coagulation (DIC) is a profound hemorrhagic disorder associated with concurrent activation of procoagulant, anticoagulant, and fibrinolytic mechanisms.

PATHOPHYSIOLOGY/PATHOLOGY

Dysregulation of procoagulant, anticoagulant, and fibrinolytic pathways due to various initiating events.

Microvascular hemorrhages and thrombosis.
Procoagulant factors released in the blood may initiate DIC in acute promyelocytic leukemia.
Endotoxins released during infections cause activation of coagulation factor XII, endothelial injury, platelet aggregation, and inhibition of fibrinolysis.
Following disease processes can cause DIC:
- Infections
  - Meningococcemia
  - Gram negative and positive sepsis
  - Malaria
  - Viral and fungal sepsis
- Tissue injury
  - Massive brain injury
  - Shock or asphyxia
  - Hypothermia or hyperthermia
- Malignancies
  - Acute promyelocytic leukemia
  - Metastatic carcinomas
- Obstetric causes
  - Intrauterine fetal death
  - Amniotic fluid embolism
- Gastrointestinal
  - Fulminant hepatitis
  - Reyes syndrome
- Neonatal
  - Necrotizing enterocolitis
  - Congenital viral infections
  - Group B strep infection
  - Erythroblastosis fetalis
- Miscellaneous
  - Acute hemolytic transfusion reaction
  - Kasabach Merritt syndrome
  - Snake bite

EPIDEMIOLOGY

Exact incidence not known.
Most commonly secondary to infections.
Snake bite may be most common cause world wide.

COMPLICATIONS

Hemorrhage
- Pulmonary
- Intracranial
Renal failure
Multiorgan system failure

PROGNOSIS

Poor unless underlying disease is treated.

DIFFERENTIAL DIAGNOSIS

Coagulopathy of liver disease
Pathological fibrinolysis
Thrombotic thrombocytopenic purpura

DATA GATHERING

HISTORY

Presence of one of the underlying conditions listed in causes.
Abrupt onset of bleeding?
Pulmonary or intracranial hemorrhage?
Oliguria
Prolonged bleeding from venipuncture sites.
Major organ dysfunction
Pulmonary, renal, hepatic.

PHYSICAL EXAMINATION

Signs of underlying disease.
Generally a very sick child.
Ecchymosis and petechiae.
Bleeding from previously intact venipuncture sites.
Skin infarctions (purpura fulminans) secondary to thrombosis of dermal vessels.
Pulmonary hemorrhage, gastrointestinal bleeding, bleeding from surgical wounds, hematuria.
Intraperitoneal and pleural hemorrhages.

LABORATORY AIDS

All these tests should be checked every 8 to 12 hours as they change rapidly.

Test: CBC
Significance: Decreased platelet count, often earliest abnormality.

Test: Peripheral smear
Significance: Schistocytes, microspherocytes (50% of cases).

Test: PT, PTT, and Thrombin time
Significance: Prolonged

Test: Fibrinogen
Significance: Decreased

Test: Fibrin degradation products
Significance: Increased

Test: Factor VIII and V
Significance: Decreased, Factor VIII is normal in coagulopathy of liver disease.

THERAPY

Treat the underlying disorder.
Cryoprecipitate, platelets and fresh frozen plasma to control bleeding.
Fresh frozen plasma also replaces anticoagulants—protein C and S.
Heparin used for management of purpura fulminans due to meningococcemia.
Routine use of heparin for DIC is debatable.

SUPPORTIVE CARE

Manage other organ system failure.

ICD-9-CM 286.6

BIBLIOGRAPHY

Levi M, van der Poll T, van Deventer SJ. Pathogenesis of disseminated intravascular coagulation in sepsis. JAMA 1993;270(8):975–979.

Wheeler A, Rubenstein EB. Current management of disseminated intravascular coagulation. Oncology 1993;8(9):69–79.

Wintrobe’s clinical hematology, 10th ed., Vol. II. Baltimore: Lippincott Williams & Wilkins, 1998, 1480–1493.

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